Download - Conferencia insstrumentacion 19112010
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EPIDEMIOLOGIA DE CA PULMONAR
PRIMERA CAUSA DE MUERTE POR CA 216.000 MUERTES POR AÑO 2008 USA MORTALIDAD EN > 70 AÑOS 377.6/ 100.000
HABITANTES MORTALIDAD EN HOMBRES Y MUJERES POR
IGUAL MAYOR INCIDENCIA DE MUERTE EN LA RAZA
NEGRACHEST SURGERY CLINICS 2008
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Cancer Death Rates*, for Men, US, 1930-2000
*Age-adjusted to the 2000 US standard population.Source: US Mortality Public Use Data Tapes 1960-2000, US Mortality Volumes 1930-1959, National Center for Health Statistics, Centers for Disease Control and Prevention, 2003.
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20
40
60
80
100
1930
1935
1940
1945
1950
1955
1960
1965
1970
1975
1980
1985
1990
1995
2000
Lung
Colon & rectum
Prostate
Pancreas
Stomach
Liver
Rate Per 100,000
Leukemia
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CLASIFICACIÓN HISTOPATÓLOGICA
• ADENOCARCINOMA 40%• CARCINOMA ESCAMOCELULAR 27%• CARCINOMA DE CELULAS PEQUEÑAS 19%• CARCINOMA DE CELULAS GRANDES 8%• CARCINOMA BRONQUIOLO-ALVEOLAR 4%• ADENOESCAMOSO 2%• CARCINOIDE 1%
Chest surgery clinics 2008
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SARCOMAS PULMONARES
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TUMORES BENIGNOS DEL PULMON
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TABACOTABACO COMO FACTOR DE RIESGO EL 85% DE LOS PACIENTES CON CA PULMONAR SON
FUMADORES TABACO SIN FILTRO MAYOR RIESGO 60-130 VECES
MÁS COMIENZO A EDAD TEMPRANA NIVELES DE ALQUITRA Y NICOTINA EXFUMADORES DISMINUYE EL RIESGO 50% DESPUES
DE 10 AÑOS FUMADOR PASIVO 1.3 VECES MÁS DE CA HIDROCARBUROS AROMÁTICOS (BENZOPIRENOS) PARCHE NICOTINA -BUPROPION
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FACTORES DE RIESGO OCUPACIONALES
EXPOSICIÓN A RADIACIÓN 5 – 10% GAS RANDON- URANIO COMPUESTOS INDUSTRIALE:- ALUMINIO, NIQUEL, CROMIUN- SILICE, ASBESTO- CLOROVINILOS, CLOROMETILETER,
FORMALDEHIDO- GAS MOSTAZA
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NODULO PULMONAR
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ATELECTASIA POR CANCER
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NEUMONIA POR CANCER
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DERRAME PLEURAL POR CANCER
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CANCER COMPROMISO PARED
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CANCER ABSCEDADO
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CANCER DE PULMON
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CANCER MEDIASTINO ANTERIOR
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TUMOR DE PANCOAST
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TUMOR DEL SULCUS SUPERIOR
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TRATAMIENTO
I Y II: CIRUGÍA (LOBECTOMÍA, BILOBECTOMÍA, NEUMONECTOMÍA CON DISECCIÓN GANGLIONAR)
IIIA: QT Y RT. CIRUGÍAIIIB: QT Y RT O RT SOLAIV: QT O RT PALIATIVA• CÉLULAS NO PEQUEÑAS: QT Y RT
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DIVISIONES DEL MEDIASTINO
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PATOLOGIA DEL MEDIASTINO ANTERIOR
• TUMORES TIMICOS• TUMORES DE CELULAS GERMINALES• LINFOMAS• TUMORES MESENQUIMALES• BOSIO INTRATORACICOS• ANEURISMAS AORTICOS• CANCER DEL PULMON
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PATOLOGIA DEL MEDIASTINO MEDIO
• GANGLIOS LINFATICOS• QUISTES BRONCOGENICOS• QUISTES PERICARDICOS• MEDIASTINITIS• PERICARDITIS• ANEURISMAS DE LA ARTERIA PULMONAR
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PATOLOGIA DEL MEDIASTINO POSTERIOR
• TUMORES NEUROGENICOS• QUISTES ENTERICOS• TUMORES DEL ESOFAGO• HERNIAS DIAFRAGMATICAS• ANEURISMAS DE LA AORTA DESCENDENTE• HAMATOPOYESIS EXTRAMEDULAR
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ESTUDIO DE MASAS MEDIASTINALES
• ESTUDIOS DE IMÁGENES, RX DE TORAX, TAC , RNM, PET
• MARCADORES TUMORALES• BIOPSIA DIRIGIDAS POR TAC O ECOGRAFIA• MEDIASTINOSCOPIA• MEDIASTINOTOMIA ANTERIOR• VIDEOTORACOSCOPIA
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MANEJO QUIRURGICO
• BIOPSIAS• RESECCIONES TUMORALES• RESECCIONES DE LESIONES QUISTICAS• TECNICAS: • MEDIASTINOSCOPIA• VIDEOTORACOSCOPIA • TORACOTOMIA• ESTERNOTOMIA
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BOSIO INTRATORACICO
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TIMOMA
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TIMOMA QUISTICO
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TIMOMA INVASIVO
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TIMOMA INVASIVO
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TERATOMA MALIGNO
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ADENOPATIAS MEDIASTINALES
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CARCINOMA DE CELULAS PEQUEÑAS DE PULMON
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SINDROME DE VENA CAVA SUPEROR
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SINDROME VENA CAVA POR LINFOMA
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MEDIASTINITIS
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QUISTE BRONCOGENICO
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SHWANOMA MEDIASTINAL
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TUMOR NEUROGENICO
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INFECCIONES PULMONAES
• TUBERCULOSIS PULMONAR• ASPERGILOSIS• COCIDIODOMICOSIS• ABSCESOS PULMONARES• GANGRENA PULMONAR• HIV
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TUBERCULOSIS PULMONAR
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BRONQUIECTASIAS QUISTICAS
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FISTULA BRONCOPLEURAL
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FIBROTORAX
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TBC MULTIRESISTENTE
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COCCIDIOIDOMICOSIS
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COCCIDIOIDOMICOSIS
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ABSCESO PULMONAR
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ABSCESO PULMONARABSCESO PULMONAR
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NEUMONIA NECROTIZANTE
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GANGRENA PULMONAR
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ENFERMEDADES PARENQUIMATOSAS
• ENFERMEDADES INTERSTICIAL• ENFISEMA PULMONAR
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NEUMONIA INTERSTICIAL
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NEUMONIA INTERSTICIAL
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FIBROSIS PULMONAR
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BULA ENFISEMATOSA
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BULAS PULMONARES
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ENFISEMA PULMONAR
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ENFISEMA PULMONAR
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PLEURAS
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ECO TORAX
• Derrame loculado y pequeño• Identifica tabiques mejor que la TAC• Calcula volumen de líquido• Bajo costo • Portátil
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• Indicaciones: – Paciente en Ventilación
Mecánica– Neumotórax > 30%– Paciente clínicamente
inestable o sintomático– Neumotórax a tensión– Neumotórax recurrente
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NEUMOTORAX
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NEUMOTORAX ESPONTANEO
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NEUMOTORAX A TENSION
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FISTULA BRONCOPLEURAL
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• Indicaciones: – Hemoneumotórax– Hemotórax >500ml– Cualquier volumen
en paciente sintomático
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ETIOLOGIA DERRAME PLEURAL
• PULMONARES• PLEURAL• EXTRAPULMONAR
• ICC• NEUMONIA• CANCER• EMBOLISMO• VIRAL• PUENTES CORONARIOS• CIRROSIS CON ASCITIS• COLAGENOSIS
N Engl J Med; Vol 346, 1971
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DERRAME PLEURAL
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DERRAME PLEURAL BILATERAL
• No puncionar los dos lados
• Patología sistémica ICC Malignidad LES AR
Chest 2003; 124:167
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DERRAME PLEURAL MASIVO
• 766 pacientes total• 93 pacientes con
derrame masivo• Malignidad 55%• Paraneumonico 22%• Tuberculosis 12%
Chest 2003; 124: 978
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DERRAME CON CAMBIOS EN PAREMQUIMA
Malignidad
Embolismo pulmonar
Infección pulmonar
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EMPIEMA PLEURAL
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EMPIEMA LOCULADO
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ENGROSAMIENTOS PLEURALES
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TUMOR FIBROSO DE PLEURA
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MESOTELIOMA MALIGNO
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PATOLOGIA CONGENITA
• QUISTES BRONCOGENICOS• SECUESTROS PULMONARES• ENFISEMA LOBAR CONGENITO• FIBROSIS QUISTICA• FISTULAS ARTERIO VENOSAS• MALFORMACIONES DE LA PARED TORACICA
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QUISTE BRONCOGENICO
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QUISTE BRONCOGENICO
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QUISTE PERICARDICO
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SECUESTRO EXTRAPULMONAR
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ENFISEMA LOBAR CONGENITO
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BRONQUIECTASIAS POR FIBROSIS QUISTICA
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FISTULA ARTERIO VENOSA PULMONAR
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PECTUS CARINATUM
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CORRECCION
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LESIONES BENIGNAS DE LA PARED TORACICA
• CONDROMAS• OSTEOCONDROMAS• DISPLASIA FIBROSA• TUMORES DE CELULAS GIGANTES• TUMORES DESMOIDES• LIPOMAS• FIBROMAS• LINGANGIOMAS• HEMANGIOMAS• NEUROFIBROMAS• RADIODERMITIS• OSTEOMIELITIS ESTERNAL
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RADIODERMITIS
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INFECCION ESTERNAL
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TUMORES MALIGNOS DE LA PARED TORACICA
• CONDROSARCOMAS• OSTEOSARCOMAS• SARCOMAS DE EWING• TUMOR DE ASKIN• PLASMOCITOMAS SOLITARIO• SARCOMAS DE TEJIDOS BLANDOS• HISTIOCITOMA FIBROSO MALIGNO
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CONDROSARCOMA
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OSTEOSARCOMA
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TUMOR PARED TORACICA
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LARINGE
LARINGOESOFÁGICO
LARINGOTRAQUEAL
TRAQUEA
PATOLOGIA DE LA VIA AEREA
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Masas tiroides, metástasis, vasosLesiones invasoras tiroides, esófagoFibrosis mediastinal tuberculosis, histoplasmosis
Congénitas estenosis traqueal congénita
Infecciosascrup, papilomatosis, tuberculosis, escleroma, hongos
Granulomatosas WegenerSarcoidosis
Neoplásicas Benignas, malignas, linfomaTraumáticas Traqueostomía, intubaciónPostinflamatoria Epidermolisis bulosaDepósito/Displásica Mucopolisacaridosis
Condrodisplasia punctataInmunológica Amiloidosis, policondritisCriptogénica Traqueopatía, idiopática
CAUSAS INTRÍNSECAS
CAUSAS EXTRÍNSECAS
ESTENOSIS LARINGOTRAQUEAL
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Estenosis Complejas
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Trauma
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PAPILOMA TRAQUEAL
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HAMARTOMA BRONQUIAL
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Tumores
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TUMOR TRAQUEAL
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CARCINOMA ENDOBRONQUIAL
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TUMOR ENDOBRONQUIAL
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TUMOR CARCINOIDE
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TUMOR ADENOIDE QUISTICO DE LA TRAQUEA
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TRASPLANTE DE LARINGE
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PROCEDIMIENTOS DIAGNOSTICOS
• BRONCOSCOPIA FLEXIBLE• BRONCOSCOPIA RIGIDA• MEDIASTINOSCOPIA• MEDIASTINOTOMIA ANTERIOR• TORACOSCOPIA• BIOPSIAS TRASTORACICAS• BIOPSIAS CON AGUJA DE PLEURA• BIOPSIAS ESCALENICAS
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BRONCOSCOPIA
SENSIBILIDAD-90% LESIONES ENDOBRONQUIALES-71% LESIONES PERIFÉRICAS
DIAGNÓSTICO HISTOLÓGICORESECABILIDAD
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FIBROBRONCOSCOPIA
BIOPSIA DIRECTA, ASPIRACIÓN TRANSBRONQUIAL CON AGUJA, CEPILLADO, LAVADO
GUÍA FLUOROSCÓPICACOMBINACIÓN AUMENTA RENDIMIENTO DXTUMOR ENDOBRONQUIAL, INSTRUMENTACIÓNEBUS-FNA
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BIOPSIA TRANSBRONQUIAL
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TUMOR DE LA CARINA
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EBUS-FNA
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DRENAJE LINFATICO MEDIATINAL
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BRONCOSCOPIA RIGIDA
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BRONCOSCOPIOS RIGIDOS
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ESTENOSIS TRAQUEAL
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DILATACIÓN CON BALON
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LÁSER CO2
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TUMOR TRAQUEAL
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DILATACIÓN CON BALON
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ENFERMEDADES MALIGNAS
EROSION
MIGRACION
Prótesis
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MEDIASTINOSCOPIA CERVICAL
• SENSIBILIDAD 89 A 95%• INDICACIONES:- GANGLIOS MEDIASTINALES >1 CM POR TAC- PROTOCOLO DE NEOADYUVANCIA- TAC NEGATIVO CON T2 Y T3 CENTRALES- ADENO CA Y CA DE CELULAS GRANDES
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MEDIASTINOSCOPIO
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Mediastinoscopia Cervical
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MEDIASTINOSCOPIA
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ESTACIONES GANGLIONARES
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MEDIASTINOSCOPIA
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MEDIASTINOSCOPIA
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MEDIASTINOTOMIA ANTERIOR
• VENTANA AORTO-PULMONAR Y MEDIASTINO ANTERIOR
• INDICACIONES:- TUMOR DEL HILIO IZQUIERDO O LOB SUP IZQ- PROTOCOLO DE NEOADYUVANCIA- EVALUACIÓN DE ENFERMEDAD
EXTRACAPSULAR- PARALISIS LARINGEO RECURRENTE IZQ
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MEDIASTINOTOMIA ANTERIOR
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TORACOSCOPIA DIAGNÓSTICA
NÓDULO PULMONAR SOLITARIO BIOPSIA ESTACIONES- VENTANA AORTO-PULMONAR(5)- MEDIASTINO ANTERIOR (6)- PARATRAQUEALES (2 Y 4) EVALUACIÓN PLEURAL
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VIDEOTORACOSCOPIA
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ASPIRACION PLEURAL
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BIOPSIA PLEURAL CON AGUJA
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PUNSION TRANSTORACICA
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BIOPSIA ESCALÉNICABIOPSIA ESCALÉNICA
INSOSPECHABLES 5 – 10%
DESCARTAR N3 EN PACIENTES CON N2
BIOPSIA POR ASPIRACIÓN CON AGUJA FINA GANGLIOS SUPRACLAVIVULARES
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TORACOTOMÍA DIAGNÓSTICA FRECUENCIA 5%PACIENTES ALTO RIESGO DE CA PULMONARNO METÁSTASISLESION SUGESTIVA DE CABIOPSIA POR CONGELACIÓNDETERMINAR RESCECABILIDAD TUMORAL
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BIOPSIA POR TORACOTOMIA
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EMBOLIZACION ARTERIAS BRONQUIALES
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TOMOGRAFIA DE EMISIÓN DE PROTONES (PET)
• FLUORODEOXIGLUCOSA-DETECTA RATA DE GLUCÓLISIS• ALTA SENSIBILIDAD Y ESPECIFICIDAD PARA DIFERENCIAR
LESIONES MALIGNAS Y BENIGNAS DE PULMÓN 93%• DETECCIÓN DE GANGLIOS MEDIASTINALES
METASTÁSICOS 98%• DETECCIÓN DE METÁSTASIS EXTRAPULMONARES 96%
Chest surgery clinics 2000
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PECT-CT NODULO PULMONAR
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PET-CT EN CANCER PULMONAR
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PET-CT METASTASIS MEDIASTINAL
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PROCEDIMIENTOS QUIRURGICOS
• TORACOTOMIAS• TORACOSTOMIAS• VIDEOTORACOSCOPIA• ESTERNOTOMIAS• TRASPLANTE PULMONAR• CIRUGIA DE TRAQUEA• PARED TORACICA
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HILIO PULMONAR DERECHO
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HILIO PULMONAR IZQUIERDO
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INCICIONES CERVICOTORACICAS
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ABORDAJES QUIRURGICOS
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ABORDAJES QUIRURGICOS
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INCICION TIPO CLANCHEL
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TORACOTOMIA BILATERAL
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IMPLANTE PULMONAR
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TECNICA TRANSPLANTE DE PULMON
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ANASTOMOSIS DE LA AURICULA
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TORACOTOMIA POSTERO LATERAL
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TORACOTOMIA AXILAR
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ABORDAJE TORACOABDOMINAL
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TORACOTOMIA URGENTE• DRENAJE TORACICO >1500 ML, 200 ML /HORA• HEMOTORAX CUAGULADO• TAPONAMIENTO CARDIACO• LESION CARDIACA SEPTAL O VALVULAR • DEFECTOS PARED TORACICA• FISTULA BRONCOPLEURAL ALTO DEBITO• LESION DE GRANDES VASOS• PERFORACION ESOFAGICA• HERIDA DEL DIAFRAGMA
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VOLVULOS CARDIACO
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LOBECTOMIA INFERIOR IZQUIERDA
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NEUMONECTOMIA
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RESECCION CON BRONCOPLASTIA
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COLGAJO INTRATORACICO
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Cúal cirugía es mejor?
Toracotomia Video-Assisted Thoracoscopic Surgery(VATS)
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ABORDAJE TORACOSCOPIA
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INDICACIONES DE VATS LOBECTOMÍA
• ESTADIOS IA Y IB DE CÁNCER• TUMORES MENORES DE 6 CM
CONTRAINDICACIONES RELATIVAS• INTOLERANCIA A LA VENTILACIÓN UNÍ PULMONAR• TUMORES MAYORES DE 6 CM• ADENOPATÍAS HILIARES SIGNIFICATIVAS• COMPROMISO MEDIASTINAL• COMPROMISO DE LA PARED TORÁCICA
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CIRUGIA DE REDUCCION DE VOLUMEN
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TORACOSCOPIA
• Cuando no hay diagnostico• Sensibilidad 95%• Terapéutica: Pleurodesis• Complicaciones: Enfisema subcutaneo 6-9% Arritmia 0.3-5% 1 embolismo aéreo No muertes
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Agentes usados para pleurodesis
talcotalco doxiciclinadoxiciclina bleomicinableomicina
DisponibiliDisponibilidad dad
ampliaamplia ampliaamplia ampliaamplia
CostoCosto mínimomínimo mínimomínimo altoalto
EfectividadEfectividad > 90%> 90% 50-75%50-75% 60-85%60-85%
Efectos Efectos adversosadversos
++++ ++++++ ++++
ToxicidadToxicidad mínimamínima mínimamínima mínimamínima
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BRAQUITERAPIA
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RADIOFRECUENCIA
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TORACOSTOMIA ABIERTA
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TORACOSTOMIA ABIERTA
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• Emergencia: – Neumotórax a tensión– Hemotórax masivo– Hemoneumotórax– Ruptura esofágica
• No emergencia: – Derrame pleural maligno– Pleurodesis– Derrame pleural recurrente– Derrame paraneumónico o Empiema– Quilotórax– Cuidado postQx
Dev SP. Chest tube insertion. NEJM 2007; 357: e15
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• Radiólogo– Eco o TC
• Kit
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• Equipo:
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Dev SP. Chest tube insertion. NEJM 2007; 357: e15
• Diámetro del tubo según la indicación:
– 14-22 Fr Neumotórax en pcte Estable– 24-28 Fr Neumotórax en pcte Inestable
Ventilación mecánica
– 8-22 Fr Transudado o Derr. Pl. Maligno– 20-34 Fr Empiema
Hemotórax
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• Tubo de Tórax con línea Radio-opaca
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• Pinzamiento del Tubo proximal y distal
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• Triangulo de seguridad: – Borde Pectoral Mayor– LAM– 6ª costilla
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• Antisepsia y Asepsia
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• Anestesia local
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• Incisión y Disección
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• Disección ROMA
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• Liberación digital de adherencias pleurales
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• Introducción del tubo de tórax
Light RW. Pleural Diseases. 5th Ed. Parapneumonic effusions and empyema
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• Asegurar el tubo
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• Conexión al sistema de drenaje pleural
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1. Evacuar liquido o gas acumulado
2. Restaurar la presión pleural
3. Reexpandir el pulmón colapsado
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RECONSTRUCCION DE LA PARED TORACICA
• MALLAS• METILMETACRILATO• PROTESIS• PLACAS• COLGAJOS MUSCULARES• COLGAJOS DE EPIPLON• TORACOPLASTIA
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RECONSTRUCCION CON MALLA DE PROLENE
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METILMETACRILATO
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BARRAS DE TITANIO
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MOLDES DE SILICONA
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ROTACION DE PECTORALES
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TRASPOSICION DE PECTORAL
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DORSAL ANCHO
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RECONSTRUCCION CON DORSAL
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TRASPOSICION DE OMENTUM
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RECONSTRUCCION ESTERNAL
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TORACOPLASTIA
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Manejo Quirúrgico Vía Aérea
I. Endoscópico: DilataciónLáser
II. Cirugía abierta: Procedimientos de expansión. Laringotraqueoplastia.Resección laringotraqueal (RLT).
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Laringotraqueoplastia
Split (hendidura) cricoideo anteriorSplit cricoideo posteriorSplit cricoideo anterior y posterior División del cartílago cricoides en cuatro
cuadrantes.
Requieren largo tiempo con stent ( > 6 meses).
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Split cricoideo anterior
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ANASTOMOSIS LARINGO TRAQUEAL
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ANASTOMOSIS TRAQUEAL
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FISTULA TRAQUEOESOFAGICA
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Tubo en T
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Estenosis compleja
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• Otolaryn Head Neck Surg 2007
LARYNGEAL, TRACHEAL AND ESOPHAGEAL TRANSPLANTATION IN HUMANS
LUIS F. TINTINAGO, M.D., BYRON J. LÓPEZ, M.D., FIDEL CANO, M.D., MAURICIO CORRALES, M.D., ALFONSO WHITE, M.D., CLARA M. CASAS, FERNANDO ALZATE, M.D., FRANCISCO MARTINEZ, ANA C. VANEGAS, M.D., ELSY MEDINA, M.D., DIEGO
HERRERA, M.D., SONIA A. CARRERO, M.D., ELMER J. GAVIRIA, M.D.,
Background The development of new surgical techniques for the air way and upper digest tract reconstruction is the aim of current researches. This study consisted of an outcome analysis of 14 consecutive patients who received a transplant at our institution as the best option for reconstruction and improvement the quality of life.Methods Between 2002 and 2006, the authors performed 3 laryngeal, 7 tracheal, 2 laryngotracheal and 1 laryngoesophageal transplants. The arterial inflow was give by superior thyroids arteries (n=1), common carotids (n=3), subclavian arteries (n=3) and aortic arch (n=7) and venous outflow by their respective veins. Humanized anti-IL-2 receptor monoclonal antibodyor antithymocyte Globulin was use for induction immunusuppression. Triple therapy (cyclosporine micophenolato mofetil and prednisone) or double therapy (tacrolimus and prednisolone) was use for maintenance immunosuppression. The monitoring of the graft was performed with protocol bronchoscopies biopsies and ultrasonographic evaluation.Results: The revascularization has been successful in all patients. The percent of rejection at the time of follow-up was 42.9%. The mean the graft survival was 29,6 months. The successful of closed tracheostomy was 71.4%. All patients recovered the voice with different degrees of dysphonia.Conclusion: Laryngeal, tracheal and esophageal transplantation are an effective treatment for patient with complex pathologies when is not possible the reconstruction by usual methods and offers a significant improve on the quality of life.______________________________________________________________________________________________________From the Departments of Head and Neck Surgery (L.F T.), Otolaryngology (B.J.L., A.W., C.M.C.), Vascular Surgery (F.C., M.C.), Neumology (A.C.V.), Radiology (E.M., D.H.) and Anestesiology (E.J.G.);Universidad de Antoquia-Hospital San vicente de Paúl. Medellín, Colombia. Address reprint requests to Dr. Tintinago at the Department of Head and Neck Surgery, Antioquia University (address) or at [email protected]. Otolaryng Head
Neck surg 2007
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CUERPO EXTRANO INTRATORACICO
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TRASPLANTE DE LARINGE